CASE EVALUATION

TO HELP US GIVE YOU THE HIGHEST QUALITY EVALUATION PLEASE FILL OUT THE FOLLOWING INFORMATION.*
*THIS DOES NOT CREATE AN ATTORNEY CLIENT RELATIONSHIP, ONLY UPON MEETING WITH THE ATTORNEY AND SIGNING FORMAL DOCUMENTATION WILL THAT OCCUR. 

Personal Information

Are you legally authorized to work in the United States? *
Have you ever been convicted of a felony? *

Injury Type

Check all the body parts that you think were injured in your work accident or personal injury accident such as motor vehicle crash or slip and fall *
How long were you employed when the accident happened? *

Employment History

Who do you work for? (this is completely confidential and we will not share this information)
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Additional Information

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